Interview with Mala Moszkowicz, MD, specialist in child and adolescent psychiatry.
You have been one of the pioneers in Denmark developing the field peri-natal mental health. Could you elaborate on how it was developed.
In 1988-1992 the child psychiatrist Lene Lier together with the psychologist Marie Gammeltoft were in charge of a project comprising 100 pregnant women with severe psychiatric disorders identified at Copenhagen University Hospital Rigshospital’s obstetric department. An interdisciplinary team was established with participation of child and adult psychiatrist, obstetrician, midwife, and psychologist with the aim to support these pregnant women during their pregnancy and in the peri-natal period. One of the results of the intervention was that the women who were offered this special service delivered babies with a higher birth weight.
Subsequently, in 1992 Copenhagen University Hospital Bispebjerg established an infant psychiatric unit where I joined in 1993. Again, the team was consisting of child psychiatrist, psychologist, and health nurse (sundhedsplejerske). Our focus was close interdisciplinary collaboration with adult psychiatrist, obstetrician, and pediatrician as well as interdisciplinary collaboration with general practitioner, health nurses, and municipal services.
The target group was mainly seriously mentally ill pregnant women and 0-3 years old children with mothers with a psychiatric disorder while we initially received few referrals of children who themselves had psychiatric disorders. Today both target groups are the subject of investigation and treatment in infant psychiatry.
How did the model change over the years?
Well, with changing family patterns we experienced from the late 1990’s that fathers played an increasing role – both fathers with psychiatric disorders who could be referred and fathers who were not ill but due to the mother’s mental illness could be given the role as the primary caretaker. So today we do no longer talk about mother-child relation and intervention but parent-child relations with important focus on the fathers too.
What is the situation today regarding available programs?
We see several services in the country differing in focus, but all concerned with peri-natal mental health.
We have in Denmark 4 independent infant psychiatry units in the 4 different health regions, but the 5th region to my knowledge does not provide this service. The units differ to some degree – from having children aged 0-3 as their exclusive target, to providing service both to sick 0-3 years old as well as parents with psychiatric disorders.
With respect to obstetric departments all regional departments have some kind of interdisciplinary collaboration with the local psychiatric department, with child psychiatric department (if available) as well as with general practitioners.
We also have a Competence Center for Affective Disorders in Copenhagen providing counselling and treatment to pregnant women and new mothers with severe depression and bipolar disorder.
Furthermore, we have pre-conceptual counselling that is a service directed towards couples where one or both parents have a serious psychiatric illness, but where they have a wish to have a child and look for advice how to manage the pregnancy and peri-natal period in the optimal way.
What do you see as the greatest challenges?
An overall problem that receives a lot of political attention these days is the shortage of qualified staff. We are lacking trained child psychiatrists with the result that there are long waiting lists, there is a shortage of beds in psychiatry, there is a lack of nurses, midwifes, etc. Previously the vulnerable mothers were allocated to special midwifes who provided extra support and time – this is rarely the case now. The prophylactic aspects are suffering as we only have resources to those already in treatment, whereas those who have been discharged may be forgotten.
So, with your long experience what do you recommend if we want to optimize peri-natal mental health?
I think many ways could be taken. First, a large proportion of psychiatric patients is in the fertile part of life which means that pregnancy is an issue to have in mind and discuss with the patients. Pre-conceptual counselling may here be very relevant, and time well spent supporting the future parents. We should also remember that risk factors may relate both to pre-natal, peri-natal and post-natal periods. Early intervention is crucial – research e.g. by Professor Anne Thorup has shown that children who at the age of 7 exhibit psychiatric problems may have had problems at an earlier age.
Interdisciplinary collaboration between sectors – primary health, municipal social services and the secondary health system is vital.
Finally, I would like to stress the general information provided by different agencies to increase the general awareness of peri-natal mental health. □